Retiring the “Against Medical Advice” Discharge
Authors: Robert A. Kleinman, Thomas D. Brothers, Nathaniel P. Morris
Journal: Annals of Internal Medicine (2022)

Ideas and OpinionsDecember 2022Retiring the “Against Medical Advice” DischargeRobert A. Kleinman, MD, Thomas D. Brothers, MD, and Nathaniel P. Morris, MDRobert A. Kleinman, MDCentre for Addiction and Mental Health, and Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada (R.A.K.)Search for more papers by this author, Thomas D. Brothers, MDDepartment of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada, and UCL Collaborative Centre for Inclusion Health, University College London, London, United Kingdom (T.D.B.)Search for more papers by this author, and Nathaniel P. Morris, MDDepartment of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California (N.P.M.).Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M22-2964 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Most clinicians are familiar with the following scenario: A patient hospitalized with a serious illness asks to leave. The patient's illness would likely improve with further treatment, but despite entreaties from the clinical team, the patient wishes to go. Following hospital policy, a clinician asks the patient to sign a form describing the risks of leaving, and the patient scribbles a signature. The team completes discharge paperwork and indicates that the discharge was “against medical advice,” or “AMA.” We believe it is time to retire the “AMA” designation.Against medical advice discharges are common, particularly among patients facing socioeconomic disadvantages. ...References1. Agency for Healthcare Research and Quality. Healthcare Cost and Utilization Project (HCUPnet). Accessed at https://datatools.ahrq.gov/hcupnet on 17 October 2022. Google Scholar2. Eaton EF, Westfall AO, McClesky B, et al. In-hospital illicit drug use and patient-directed discharge: barriers to care for patients with injection-related infections. Open Forum Infect Dis. 2020;7:ofaa074. [PMID: 32258203] doi:10.1093/ofid/ofaa074 CrossrefMedlineGoogle Scholar3. Alfandre D. Reconsidering against medical advice discharges: embracing patient-centeredness to promote high quality care and a renewed research agenda. J Gen Intern Med. 2013;28:1657-62. [PMID: 23818160] doi:10.1007/s11606-013-2540-z CrossrefMedlineGoogle Scholar4. Simon R, Snow R, Wakeman S. Understanding why patients with substance use disorders leave the hospital against medical advice: a qualitative study. Subst Abus. 2020;41:519-25. [PMID: 31638862] doi:10.1080/08897077.2019.1671942 CrossrefMedlineGoogle Scholar5. Ti L, Ti L. Leaving the hospital against medical advice among people who use illicit drugs: a systematic review. Am J Public Health. 2015;105:e53-9. [PMID: 26469651] doi:10.2105/AJPH.2015.302885 CrossrefMedlineGoogle Scholar6. Southern WN, Nahvi S, Arnsten JH. Increased risk of mortality and readmission among patients discharged against medical advice. Am J Med. 2012;125:594-602. [PMID: 22513194] doi:10.1016/j.amjmed.2011.12.017 CrossrefMedlineGoogle Scholar7. Wigder HN, Propp DA, Leslie K, et al. Insurance companies refusing payment for patients who leave the emergency department against medical advice is a myth [Letter]. Ann Emerg Med. 2010;55:393. [PMID: 20346845] doi:10.1016/j.annemergmed.2009.11.024 CrossrefMedlineGoogle Scholar8. Schaefer GR, Matus H, Schumann JH, et al. Financial responsibility of hospitalized patients who left against medical advice: medical urban legend. J Gen Intern Med. 2012;27:825-30. [PMID: 22331399] doi:10.1007/s11606-012-1984-x CrossrefMedlineGoogle Scholar9. Canadian Medical Protective Association. Leaving against medical advice (AMA). Good Practices Guide. Accessed at www.cmpa-acpm.ca/serve/docs/ela/goodpracticesguide/pages/communication/Informed_Discharge/leaving_against_medical_advice-e.html on 17 October 2022. Google Scholar10. Levy F, Mareiniss DP, Iacovelli C. The importance of a proper against-medical-advice (AMA) discharge: how signing out AMA may create significant liability protection for providers. J Emerg Med. 2012;43:516-20. [PMID: 21715123] doi:10.1016/j.jemermed.2011.05.030 CrossrefMedlineGoogle Scholar Author, Article, and Disclosure InformationAffiliations: Centre for Addiction and Mental Health, and Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada (R.A.K.)Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada, and UCL Collaborative Centre for Inclusion Health, University College London, London, United Kingdom (T.D.B.)Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, San Francisco, California (N.P.M.).Financial Support: Dr. Brothers is supported by a Dalhousie University Internal Medicine Research Foundation Fellowship and a Canadian Institutes of Health Research Fellowship (CIHR-FRN# 171259).Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M22-2964.Corresponding Author: Robert A. Kleinman, MD, Centre for Addiction and Mental Health, 100 Stokes Street, Toronto, ON, Canada M6J 1H4; e-mail, robert.[email protected]ca.Author Contributions: Conception and design: R.A. Kleinman, T.D. Brothers, N.P. Morris.Drafting of the article: R.A. Kleinman, T.D. Brothers, N.P. Morris.Critical revision for important intellectual content: R.A. Kleinman, T.D. Brothers, N.P. Morris.Final approval of the article: R.A. Kleinman, T.D. Brothers, N.P. Morris.This article was published at Annals.org on 29 November 2022. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoAnnals On Call - Against Medical Advice: We Need Better Terminology Robert M. Centor and Robert A. Kleinman Metrics December 2022Volume 175, Issue 12Page: 1761-1762KeywordsBehaviorDisclosureDrug abuseDrugsFellowshipsHealth care providersInpatientsPainPsychiatry and mental health ePublished: 29 November 2022 Issue Published: December 2022 Copyright & PermissionsCopyright © 2022 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...